After a stirring welcome, we hear the famed tale of James Lind’s scurvy trial. Lind was an 18thcentury Scottish naval surgeon who allegedly divided 12 scurvy-afflicted sailors aboard the HMS Salisbury into 6 groups of 2. He offered each dyad the same diet plus either of the following unpleasant supplements: a quart of cider; several drops of sulphuric acid; a few spoonsful of vinegar; half a pint of sea water; 2 oranges and a lemon; or a spicy paste and barley water.

According to Lind’s own accounts, only the group that received cider and the group that received the citrus fruits showed improvement, with the latter recovering fully within a week. Lind’s experiment is frequently hailed as one of the first randomised controlled experiments. However, once stripped down to its bare essentials–a working theory of change, the right materials, and an evaluation plan–this classic experiment is just one of many early rapid evaluation approaches. We would spend the next 2 days of the workshop dissecting our own project into these three components using the Centre’s IDEAS Impact Framework.

Day 2 – A Theory for Everything

Of the over 100 attendees on Day 1, nine teams of 6-8 attendees returned for Day 2 to share their current projects in the field of early childhood health and development, and to begin working through the first two components of the IDEAS Impact Framework: theory of change (ToC), and programme and materials development.

The scope within the room was global, with project teams from Bangladesh, England, Uganda and the US. Projects also varied in innovation and complexity, from a small-scale text-based application to help parents monitor their child’s development, to our large-scale experiment: the Family Nurse Partnership Accelerated Design and Rapid Programme Testing (FNP ADAPT) project. Now in our second year of adaptation and testing, we were eager to review our own working theories on how best to identify and target the young pregnant women who can benefit the most from FNP (clients), and what strategies and tools work best given the clients’ contexts. This of course, is all in service of improving the outcomes for mothers and children..

The fruit of our labour was a ‘living’ ToC. In building this ToC, we first zeroed in on the needs of the client. We then identified the unique strategies and actions FNP uses to address these needs that are above and beyond the standard maternal services available. We added the outputs that might result from these actions, followed by intermediate to long-term outcomes that might emerge within the project’s timeframe. It was a useful exercise in strategic thinking and, as we’d be reminded on Day 3, it’s a very iterative process.

The last task for the day was to review the content of some of our project materials within the frame of our new, refreshed ToC. At days end, the messages ingrained in our minds were precision and fidelity. If we had confidence in our ToC, we had to do it the courtesy of implementing, and testing it, with the utmost care.

Day 3 – Seeing Things More Clearly

On the final day of the workshop, we were reminded of the complex nature of the FNP ADAPT project as we were challenged on how to evaluate our proposed ToC. We asked ourselves the following:

What research questions must we ask?

What minimum qualitative and quantitative data must we collect to answer them?

Who should collect data, and how do we ensure that data collection is useful and not burdensome (to collectors)?

Over what period can we expect to observe changes and therefore, what constitutes a cycle in rapid adaptation and testing?

The intensive nature of the workshop meant we made rapid progress towards addressing these questions. What’s more, we were armed with the skills to communicate our ToC. This is especially crucial in helping the family nurses to understand the changes we are asking them to make and the underlying imperative to improve outcomes for clients that drives the whole FNP ADAPT project.

Service Design Lessons Well Learned

One phrase that was constantly repeated over the 3 days is ‘less is more’. Doing only the necessary amount of work in the right way, based on quality evidence and plausibility, should be our special modus operandi. In our experience, it helps us, and those we work with on design and evaluation, to address the difficult question of what the project cannot reasonably achieve. We spent the 3 days of the workshop confronting this question, and walked away with fresh ideas to guide and (re)focus the FNP ADAPT project.

A second takeaway for us is that everything we do is iterative. The very essence of rapid cycle testing and adaptation is constant review, learning, and revision, and ‘building from the ground floor (and hopefully each subsequent floor) upwards’. Importantly, the feasibility and acceptability of a project to users lays the foundation for such progress. Then, successful implementation rather than proof of impact becomes the focus: without the former, the latter is impossible. We constantly reflected upon this, particularly when devising our evaluation plan. We’re often impatient to know the effect on outcomes, but certainty about implementation quality must come first.

Harvard alum John F. Kennedy said, ‘We choose to go to the moon … and do the other things, not because they are easy, but because they are hard.’ It’s no secret that our work at the Lab is challenging: our projects are large and complex, some of our methods are still in their infancy, and our success often hinges on influencing changes in human behaviour. Yet we choose to persevere, do and learn, and our experience at the Frontiers of Innovation reminded us that we are not alone!

The 4thannual Frontiers of Innovation Workshop was hosted by the Centre on the Developing Child, Harvard University, from 7 May to 9 May 2018.